we routinely do , as most of our patient are rheumatic and hence having a dilated heart and AF is common . we use digoxin as a rate control and for 6 month postop. until symptoms of HF is controlled and remodeling started. but I did not read a EBM regard this issue

Thanks for your quick responses.

Dr. Elkhayat, you said the purpose of using digoxin is for rate control. But you know the guideline recommends beta blocker or calcium antagonist as the first line drug for rate control. I'd rather think of the inotropic effect of digoxin than rate control for this indication. Could you tell me what medication other than digoxin would you prescribe for those patients? And have you noticed that withdrawal of digoxin will cause relapse of heart failure as reported in the literature?

Dr. Cocco, I agree with you that the prescription must be individualized. But personalized medication is still hard in clinical practice. BTW, what's the mechanism for digoxin to improve diastolic heart failure, rate control? Since digoxin will increase the intracellular Ca2+ concentration and make the cardiomyocytes less relaxed.

We haven't abandoned Digoxin.We have seen in clinical practice it works wonderfully in post operative period too.

I think digoxin may use in patients with atrial fibrillation or depressed left ventricular systolic function.

Most of the post operative cases are at risk of atrial arrhythmias. Digoxin is one of the drugs commonly used in Post op patients. Digoxin toxicity is probably rarely reported when you follow up in 3 months period. Mostly from my limited experience of (15 yrs in India) -the surgeons prescribe Digoxin for 5 days a week for 3 mths and the reviewing cardiologist decides to prolong or discontinue based on patient symptoms/ blood results. Digoxin toxicity could be picked up early by nausea/ vomiting. Increased potassium could lead to life threatening arrhythmias. Hyperkalemia is an independent risk factor of severe digoxin toxicity.

I do prescribe digoxin but it is not my first line of choice. I generally reserve it for when I have at least two indications for it, for example CHF along with Afib with rapid ventricular response. Or if someone has afib with poorly controlled rate and borderline/low BP. In older patients with CRI, I am a little bit more wary of it, and will check levels.

It seemed that you focused on heart failure rather than arrhythmia when considering digoxin for post-valve replacement patients. I would still prefer ACEI or beta-blockers in combination with diuretics for heart failure. Hypokalemia may sometimes occur in the postoperation periods during the diuretic phase. And the potassium levels are always a concern when using digoxin. For postoperation Afib, I will still try to find out the possible causes of Afib before treatment. Digoxin might be considered for those who have Afib with hypotension. However, as most experts mentioned, digoxin might not be the fist choice nowadays.

Thank all for your responses. Now it becomes clear for me that digoxin is better reserved for those patients who have aFib with rapid ventricular rate, especially with hypotension. But it is still okay to use digoxin postoperatively for short period as 3 months.

In practice, for those patients with aFib after operation, my first choice is amiodarone. So, again, digoxin seems to be marginalized.

Digoxin is an ancient drug that works perfectly in the case of sistolic heart failure with or without atrial fibrilation. It is cheap and available even in poor countrys. Be carefull with the guidelines writen only for rich people and rich countrys

I share Dr Domenech's views. That's my clinical attitude and I do not have the horrendous reports cited in reviews; though I go the route of slow digitalisation

Prof B N Okeahialam, Jos University Teaching Hospital Jos, Nigeria

First of all we should take into consideration why HF symptoms persisted after valve surgery (1. mismatch patient/ prosthesis in aortic stenosis or 2. big, dilated left ventricule in long lasting aortic regurgitation or 3. severly hypertrophied left ventricule with advanced diastolic dysfunction in aortic stenosis or 4. small left ventricule after MVR in severe mitral stenosis or 5. significant paravalvular leak or dysfunction etc.). In all these mentioned above clinical situations patients have symptoms of HF but of course Digoxin should not be introduced as a first line therapy after cardiac operation. I personally start with small dose of carvedilol together with diuretics ( loop diuretic plus Eplerenone ) , next small dose of ACE inhibitors and than digoxin or ivabradine, but only in clinical situation 2 or 4. I have no observed any spectacular results of digoxin in diastolic dysfunction working over 20 years in Cardiac Surgery Dept. And finally , in case when HF syptoms depends on fast ventricular rhythm in AF using digoxin together with B-blocker can be also reasonable in selected cases. .

I use it as one of the last options when heart failure medication is not sufficient. It does not work for every patient, but I think it is worth a try. Last patient had an emergency CABG and MVR and is still dependent on inotropic support despite optimal heart failure medication including digoxin.

digoxin is wonderfully used to stable cardiac rythm -control ventricular response also at low dose and to prevent AF expecially with depressed left ventricular function - the most important point is monitoring creatinine levels and electrolytes

The first choice is properly fitted beta-blocker. The electrolyte and kidney balance should be obtained. The loop diuretic (furosemide, toramide) should be necessary with optional MRA. After that - digoxin may be considered. Best regards, Rafal Dabrowski

I usually prescribe Digoxin for atrial fibrillation. With the availability of ACE inhibitors and ARBs Digoxin is no longer my first choice for heart failure. But I do prescribe it for heart failure if patients are still in failure despite these medications.

in the situations such as a :1-RVR AF ,2-sign or symptom of congestion despite full GDMT ,and 3-Right sided heart failure you can prescribe the Digoxin

Best Regards.Davood Shafie,Fellowship of heart failure and transplantation

In our practice we use digoxin just in case of rapid AF conduction or right heart failure.

The only indication is AF with tachycardia in pt with systolic dysfunction ( after AVR).

Digoxin is not commonly used in USA but it has been extensively used in Europa and South America. I think it is important to know if there is a previous history of systolic dysfunction recurrent hospitalizations. If there is no clear contraindication I would use of HF symptoms do not improve.

Whilst digoxin is clearly not primary therapy for any sort of heart failure, it may be useful particularly in heart failure with uncontrolled ventricular rates - it would be interesting to compare its efficacy with that of ivabradine. I suspect that's a trial which may not happen!. My personal practice is to continue digoxin in those patients who are already on it (unless there is renal impairment) but rarely to initiate it.

I agree with Josef Veselka: It is a first-line therapy in AF with tachycardia, only. It may be consided as add-on if systolic function remains altered after AVR and standard neurohumoral therapy.

In our practise, we use digoxin only in cases of AF with CHF. Digoxin still have narrow theraputic level and patinet can easly got lethal level with hypokalemia or even hypoxia. So i guss it is kept to very selected indicarions nowadays.

We use it routinely in patients of Valve replacement , espl mitral, with heart failure even when pt is in NSR . Obviously it is not a stand alone therapy but the mildly positive ionotropy that Digoxin possesses is very desirable in these patients nd infact can provide just that subtle kick that these patients on the brink need.

In our clinical practice, we surely prescribe it to patients with AF, rapid VR and CHF.In my opinion, RV function afer essp. mitral valve replacement should be another criteria for us to decide digoxin usage. We also use it for the patients with an EF lower than 40% and a Large RV.

Cardiomegaly and S3 gallop should be compelling  reasons to using digoxin, beyond AF nd heart failure.

We are using digoxin   in this indication of refractory failure with the usual caveats of making sure other slowing down medications are not on board. Evidence can be a funny thing sometimes not really showing the benefit of some of the traditional drugs.

In presence of AF and CHF, dig does help....potassium and serum dig levels needs to be looked into specially patients presenting with nausea and vomiting.